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Case Report 


Mai Mokhtar Yousuf et al, 2019;3(7):632–635.

International Journal of Medicine in Developing Countries

Cervical pregnancy successfully treated with US-guided intra-amniotic methotrexate injection after the failure of IM methotrexate: a case report

Mai Mokhtar Yousuf1*, Gamal Mohamed Elaswally1

Correspondence to: Mai Mokhtar Yousuf

*Madinah Maternity and Children Hospital, Madinah, Saudi Arabia.

Email: dr.m_y [at] live.com

Full list of author information is available at the end of the article.

Received: 23 January 2019 | Accepted: 05 February 2019


ABSTRACT

Background:

Cervical pregnancy is a rare ectopic pregnancy caused due to implantation of the ovum in the endocervical canal. In the past, early diagnosis for such condition was not possible; as a result, this condition often was presented lately to the clinics with life-threatening hemorrhage that frequently required a hysterectomy. At present, there has been a tremendous development in the medical field which led to early diagnosis of ectopic pregnancy using ultrasonography (U/S) and sensitive serum 0-hCG assay. Such techniques allow a more conservative therapeutic approach, resulting in low morbidity and mortality rates.


Case Presentation:

A 38-year-old woman, gravida 2, para 1, was presented with painless vaginal bleeding. Early cervical pregnancy was diagnosed using transvaginal U/S. Intramuscular methotrexate (IM MTX) therapy was started without success, and an intra-amniotic injection of MTX was performed under U/S guidance. Pregnancy was terminated successfully, without complications.


Conclusion:

Local MTX is an effective and safe method.


Keywords:

Cervical pregnancy, methotrexate, conservative treatment.


Introduction

Cervical pregnancy is a rare ectopic pregnancy and it is implantation of the ovum in the endocervical canal. The incidence is 1 in 1,000 [1] to 1 in 95,000 [2] of pregnancies, which accounts for about 0.15% of ectopic pregnancies [3]. This condition was described in 1817 and first named as such in 1860 [4]. Causes of cervical pregnancy are unknown, four postulates were provided to explain it. Studdiford [5] postulated rapid crossing of the ovum through the endometrial cavity could be the cause of cervical implantation. Schneider [6] believed that the speed of travel, coupled with the rate of ripening, may determine the site of implantation. Ellingson [7] proposed that an unfertilized ovum may reach the cervix and implanted, and Illy [8], in 1968, suggested that delaying ovulation and fertilization concerning the menstrual cycle and ovum displacement by the menstrual flow lead to cervix implantation may be the reason. After that, the cervix cannot satisfy the needs of the growing ovum, as the incomplete decidual reaction hinders normal placentation. Because cervix is mainly fibrous connective tissue, with just 15% of smooth muscle, direct invasion of trophoblasts into the fibromuscular cervix produces edema, necrosis, hemorrhage, and round cell infiltration.

Pregnancy may terminate when invasion, erosion, or rupture of a large vessel results in bleeding. The inadequate decidual response in the cervix results in abnormal attachment of the placenta, accompanying an incomplete separation and profuse bleeding, which would explain the high intraoperative and postoperative maternal morbidity and mortality. Several studies have indicated a high incidence of prior dilation and curettage [1,9], use of the intrauterine device and pelvic inflammatory disease [10], and in vitro fertilization (IVF) [11,12] among females with cervical ectopic pregnancy. Clinically, the patient would present a history of amenorrhea and then uterine bleeding without crampy pain. The signs that indicate this pathology include a soft cervix that is enlarged compared to the uterus, a partially open external os, and excessive bleeding on vaginal examination.

In the past, a diagnosis used to be late and this condition often presented with life-threatening hemorrhage that frequently required a hysterectomy. Nowadays, early diagnosis has been improved by ultrasonography and sensitive serum 0-hCG assay, which allows a more conservative therapeutic approach, with the resulting low morbidity and mortality.

A case-patient is reported here who was diagnosed with cervical pregnancy and treated successfully by local methotrexate (MTX).


Case Presentation

In Madinah Maternity and Children Hospital, a 38-year-old Saudi lady, Gravida 2, Para 1+0 IVF pregnancy, presented in the emergency room complaining of mild vaginal bleeding of 2 days duration. The last menstrual period started at 4/1/1439, 8 weeks ago. The vaginal bleeding was bright red in color and little in amount started 2 days back, not associated with abdominal pain, nausea, vomiting, or dizziness. The patient had no known medical problems but one cesarean section 4 years back. Any contraceptives were not used and this pregnancy was conceived via in vitro fertilization done at a private clinic. On examination, the patient was not in distress, blood pressure was 123/68 mm Hg, and heart rate was 90 beats/minute. The abdomen was soft and not tender, the pelvic examination revealed minimal vaginal bleeding protruding through closed external cervical os. The serum quantitative Beta-human chorionic gonadotropin (Bhcg) level was 18,466 international unit (IU) and hemoglobin level was 13.6 g/dl, a transvaginal ultrasound done at a private clinic was presented which showed an ectopic gestational sac in the cervical canal containing fetal pole with positive cardiac pulsation.

Figure 1. Transvaginal US Showing 8 weeks’ cervical pregnancy.

Figure 2. Transvaginal US Showing 8 weeks’ cervical pregnancy.

Cervical pregnancy was diagnosed and the patient was admitted in the ward. During admission, she was doing fine and had no complains other than mild vaginal bleeding. Departmental ultrasound was done there and revealed fetus in the cervical canal (CRL 1.8 mm corresponding to 8 weeks + 3 days) with positive cardiac pulsation (Figure 2). Accordingly, a single dose of intramuscular (IM) MTX was counseled as it is one of the lines of treatment of cervical pregnancy. The patient agreed and 100 mg of MTX was injected as IM injection. Unfortunately, after receiving the MTX, a rise in Bhcg level was observed as 49,357 IU and ultrasound showed the 9-week fetus in the cervix with persistent cardiac activity. On the basis of these findings and stable hemodynamic status, it was decided to proceed to undergo an ultrasound-guided intra-amniotic MTX injection, which was counseled to the patient and consented. The following day in the operation room and under general anesthesia, 25 mg of MTX was injected inside the gestational sac with the guidance of transvaginal ultrasound without complications.

In the next few days, Bhcg dropped to 10,000 IU and ultrasound showed cervical canal containing mixed echogenic texture with no fetal cardiac activity. Bhcg continued to decrease for the next 3 weeks reaching 263 IU and serial ultrasound examinations revealed heterogenous echogenic texture measuring about 1 cm. One week later, Bhcg decreased to 121 IU and a clean endocervical canal was demonstrated in the ultrasound, so the patient was discharged in a stable condition. There was a follow up in the clinic after 1 week, the patient was doing well, had no complains, and Bhcg level was 29 IU.


Discussion

Diagnosing and treating cervical pregnancy have changed in the last 20 years. Before 1980, this condition would take a lot of time to get diagnosed; therefore, hysterectomy was often the only choice available. At present, various conservative treatments are performed to prevent hysterectomy and preserve fertility.

Treatment choices depend on gestational age and female desire for fertility. The surgical techniques include intracervical balloon tamponade after cervical curettage [13], cervical cerclage [14,15], angio-embolization of feeding arteries [16,17], curettage and local prostaglandin injection [18], hysteroscopic resection [19,20], and bilaterally ligating uterine or hypogastric arteries [21,22]. Non-surgical methods have been developed more recently using MTX [23,24], actinomycin-D [25], and ctoposidc [26]. Cervical curettage has a high risk of bleeding; therefore, it is rarely performed. The surgical techniques are applied only when chemotherapy fails or in emergency conditions of life-threatening bleeding. Primary hysterectomy may be appropriate in the following settings: pregnancies after 12 weeks of gestational age and in cases of intractable bleeding.

Farabow et al. [27] described the use of MTX for treating cervical pregnancy in 1983. MTX is the antagonist of folic acid, which participates in DNA synthesis, and it can stop the proliferative cell activity [28].

In 1998, Hung et al. [29] analyzed prognostic factors affecting the outcome of MTX treatment. He showed that MTX therapy was associated with higher failure rates in the presence of serum 0-hCG levels of more than 10,000 IU/l, gestational age >9 weeks, positive fetus cardiac activity, or a crown-rump length >10 mm.

In the present case, to preserve fertility, a conservative intervention was chosen, giving an IM single MTX dose, which failed to induce a decrease in hCG levels. Intra-amniotic MTX injection was done with success.


Conclusion

In conclusion, the U/S guided intra-amniotic MTX for managing cervical ectopic pregnancy appears to be an effective and safe method; however, the choice depends on gestational age, desire to preserve fertility, and hemodynamic stability.


List of abbreviations

Bhcg Beta-human chorionic gonadotropin
hCG Human chorionic gonadotropin
IVF In vitro fertilization
US Ultrasonography

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from the patient.


Ethical approval

Ethical approval is not required at our institution to publish an anonymous case report.


Author details

Mai Mokhtar Yousuf1, Gamal Mohamed Elaswally1

  1. Madinah Maternity and Children Hospital, Madinah, Saudi Arabia

References

  1. Shinagawa S, Nagayama M. Cervical pregnancy as a possible result of induced abortion. Amer J Obstetr Gynecol. 1969;105:282–4.
  2. Parente JT, Ou CS, Levy J, Legatt E. Cervical pregnancy analysis: a review and report of live ease. Obstetr Gynecol. 1983;62:79–82.
  3. Frates MC, Benson CB, Doubilet PM, Di Salvo DN, Brown DL, Laing FC, et al. Cervical ectopic pregnancy: results of conservative treatment. Radiology. 1994;191(3):773–5.
  4. Leeman LM, Wendland CL. Cervical ectopic pregnancy: diagnosis with endovaginal ultrasound examination and successful treatment with methotrexate. Arch Fam Med. 2000;9(1):72.
  5. Studdiford WL. Cervical pregnancy; a partial review of the literature & a report of two probable cases. Am J Obstetr Gynecol. 1945;49:1M.
  6. Schneider P. Distal ectopic pregnancy. Am J Surg. 1946;72:526–39.
  7. Ellingson OA. Cervical pregnancy. Southern Med J. I950;43:11.
  8. Illy L. Recent investigations concerning the aetiology of ectopic pregnancies. Austral N Zeal J Obstetr Gynecol. 1968;8:131–4. https://doi.org/10.1111/j.1479-828X.1968.tb00700.x
  9. Rothc DJ, Bimbamn SJ. Cervical pregnancy. Obstetr Gyncol. 1973;42:153
  10. Dicker D, Fcldherg D, Samuel N, Goldman JA. Etiology of cervical pregnancy. J Reprod Med. 1985;30:25–7.
  11. Ginsburg ES, Frates MC, Rein MS, Fox JH, Hornstein MD, Friedman AJ. Early diagnosis and treatment or cervical pregnancy in an in vitro fertilization program. Fertil Sleril. 1994;61:966–9.
  12. Weyerman PC, Verhoeven AT, Alberda AT. Cervical pregnancy after in vitro fertilization and embryo transfer. Amer J Obstetr Gyncol. I989;16l:1145–6.
  13. Nolan IT, Chandler PE, Hess LW, Morrison JC. Cervical pregnancy managed without hysterectomy. A case report. J Reprod Med. 1989;34:241–3.
  14. Bachus KE, Stone D, Suh B, Thickman D. Conservative management of cervical pregnancy with subsequent fertility. Amer J Obstet Gynecol. 1990;16(2):450–1.
  15. Mashiacfa S, Admon D, Oclsncr G, Paz B, Achiron Zalcl Y. Cervical Shirodkar cerclage may be the treatment modality of choice for cervical pregnancy. Hum Reprod. 2002;17:493–6. https://doi.org/10.1093/humrep/17.2.493
  16. Ryu KY, Kim SR, Cho SH, Song SY. Preoperalivc uterine artery embolization and evacuation in the management of cervical pregnancy. Report of two eases. J Korean Med Sci. 2001;16:801–4. https://doi.org/10.3346/jkms.2001.16.6.801
  17. Lobcl SM, Mcycrovitz MF, Benson CC, Goff B, Bengtson JM. Preoperative angiographic uterine artery embolization in the management of cervical pregnancy. Obstetr Gynco1. 1990;76:938–41.
  18. Spitzcr D, Steiner H, Graf A, Zajc M, Slaudach A. Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection. Hum Reprod. 1997;12:860–6. https://doi.org/10.1093/humrep/12.4.860
  19. Hardy TJ. Hysteroscopic resection of cervical ectopic pregnancy. J Amer Assoc Gynecollaparosc. 2002;9:371–1. https://doi.org/10.1016/S1074-3804(05)60419-7
  20. Ash S, Farrell SA. Hysteroscopic resection of a cervical ectopic pregnancy. Fertil Steril. 1996;66(5):842–4.
  21. Lin H, Kung FT. Combination of laparoscopic bilateral uterine artery ligation and intraamniotic methotrexate injection for conservative management of cervical pregnancy. J Amer Assoc Gynecol Laparosc. 2003;10(2):215–8.
  22. Nelson RM. Bilateral internal iliac artery ligation in cervical pregnancy: conservation of reproductive function. Amer J Obstetr Gynecol. 1979;134(2):145–50. https://doi.org/10.1016/0002-9378(79)90878-0
  23. Dotters DJ, Katz VL, Kuller JA, McCoy MC. Successful treatment of a cervical pregnancy with a single low dose methotrexate regimen. Eur J Obstetr Gynecol Reprod Biol. 1995;60(2):187–9.
  24. Timor Tritsch IE, Monteagudo A, Mantleville EO, Pcisner DB, Anaya GP, Pirronc EC. Successful management of viable cervical pregnancy by local injection of MTX guided by transvaginal ultrasonography. Amer J Obstetr Gyncol. 1991;170:737–9. https://doi.org/10.1016/S0002-9378(94)70273-X
  25. Brand E, Gibbs RS, Davidson SA. Advanced cervical pregnancy treated with actinomycin-D. Int J Obstetr Gynaecol. 1993;100(5):491–2. https://doi.org/10.1111/j.1471-0528.1993.tb15279.x
  26. Segna RA, Mitchell DR, Misas JE. Successful treatment of cervical pregnancy with oral etoposide. Obstetr Gynecol. 1990;76(5 Pt 2):945–7.
  27. Farabow WS, Fulton JW, Flcelher V, Vclat CA, White JT. Cervical pregnancy treated with MTX. N C Med J. I983;44:9.
  28. Fernandez H, Yves Vincent SC, Panthicr S, Audibcrt F, Frydman R. Randomized trial of conservative laparoscopic treatment & methotrexate administration in ectopic pregnancy and subsequent fertility. Hum Rcprod. 1998;13:3239–43. https://doi.org/10.1093/humrep/13.11.3239
  29. Hung TH, Shau WY, Hsieh TT, Hsu JJ, Soong YK, Jeng CJ. Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: a quantitative review. Hum Reprod (Oxford, England). 1998;13(9):2636–42.


How to Cite this Article
Pubmed Style

Yousuf MM, Elaswally GM. Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. IJMDC. 2019; 3(7): 632-635. doi:10.24911/IJMDC.51-1548196372


Web Style

Yousuf MM, Elaswally GM. Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. http://www.ijmdc.com/?mno=27562 [Access: August 20, 2019]. doi:10.24911/IJMDC.51-1548196372


AMA (American Medical Association) Style

Yousuf MM, Elaswally GM. Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. IJMDC. 2019; 3(7): 632-635. doi:10.24911/IJMDC.51-1548196372



Vancouver/ICMJE Style

Yousuf MM, Elaswally GM. Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. IJMDC. (2019), [cited August 20, 2019]; 3(7): 632-635. doi:10.24911/IJMDC.51-1548196372



Harvard Style

Yousuf, M. M. & Elaswally, . G. M. (2019) Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. IJMDC, 3 (7), 632-635. doi:10.24911/IJMDC.51-1548196372



Turabian Style

Yousuf, Mai Mokhtar, and Gamal Mohamed Elaswally. 2019. Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. International Journal of Medicine in Developing Countries, 3 (7), 632-635. doi:10.24911/IJMDC.51-1548196372



Chicago Style

Yousuf, Mai Mokhtar, and Gamal Mohamed Elaswally. "Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report." International Journal of Medicine in Developing Countries 3 (2019), 632-635. doi:10.24911/IJMDC.51-1548196372



MLA (The Modern Language Association) Style

Yousuf, Mai Mokhtar, and Gamal Mohamed Elaswally. "Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report." International Journal of Medicine in Developing Countries 3.7 (2019), 632-635. Print. doi:10.24911/IJMDC.51-1548196372



APA (American Psychological Association) Style

Yousuf, M. M. & Elaswally, . G. M. (2019) Cervical pregnancy successfully treated with US-guided intra-amniotic Methotrexate injection after the failure of IM Methotrexate: a case report. International Journal of Medicine in Developing Countries, 3 (7), 632-635. doi:10.24911/IJMDC.51-1548196372